Madam Wong, a G3P2, has just had a normal delivery half an hour ago. Her placenta is still not delivered yet. Discuss the management including possible complications and their treatment.

Retained placenta is found in 2 per cent of deliveries. Once the third stage of labor exceeds 30 minutes there is 10-fold increase in the risk of hemorrhage. The choice of management depends on the presence of hemorrhage which is a major complication of retained placenta. 

If there is no hemorrhage, controlled cord traction should be attempted to remove the placenta. The bladder should be emptied by catheterizing it. If the placenta is still not delivered, a vaginal examination should be performed. If the placenta is already in the vagina, it can be removed easily. 

However, if it is still in utero, the following should be done:

1.	Set up I/V line with a large bore cannula (16 or 18G).
2.	Group and cross match blood.
3.	Arrange for manual removal of placenta in theatre under general anaesthesia.

The management takes on a different route if hemorrhage is detected. As blood loss may be considerable with the possibility of leading to shock, the following have to be done immediately:

1.	Set up more than one I/V line with a large bore cannula (16 or 18G).
2.	Group and cross match – request 4 units of blood.
3.	Rub uterine fundus to produce contractions: a hand should be placed on the lower abdomen and the fundus of the uterus rubbed to stimulate a contraction. 

Next, perform a vaginal examination.

If the placenta is in the vagina:

1.	Remove placenta.
2.	Rub up uterine fundus.
3.	Administer ergometrine 0.25mg or methyl ergometrine 0.2mg I/V.

If the placenta is in utero:

1.	Administer ergometrine 0.25mg or methyl ergometrine 0.2mg IV.
2.	Prepare for manual removal of placenta in operating theatre after adequate resuscitation.

Manual removal of placenta in OT:

1.	Lithotomy position: clean, drape and catheterize.
2.	Gloved hand through cervix, follows the cord up to the placenta.
3.	Locate placenta edge and find the plane of the placenta and uterine wall.
4.	Separate the two along the plane of attachment, working fingers upwards until you have reached the frontal area, then hold the entire placenta mass in hand and remove it.
5.	Prevent uterine inversion as placenta is being withdrawn with other hand on the abdomen.
6.	After removal, check placenta for any missing parts.

If retained fragments cannot be removed in this manner, curettage with a blunt instrument may be required. Small remaining fragments of placenta can be left if there is no hemorrhage, provided there is adequate antibiotic cover and follow-up. Antibiotics should be routinely administered as there is a significant association between manual removal of the placenta and postpartum endometritis.